Financial Disclosure for Civil Monetary Penalty (CMP) Debt

ICR 201501-0960-009

OMB: 0960-0776

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2015-04-16
Supporting Statement A
2015-04-16
IC Document Collections
ICR Details
0960-0776 201501-0960-009
Historical Active 201203-0960-006
SSA
Financial Disclosure for Civil Monetary Penalty (CMP) Debt
Revision of a currently approved collection   No
Regular
Approved without change 08/24/2015
Retrieve Notice of Action (NOA) 04/28/2015
  Inventory as of this Action Requested Previously Approved
08/31/2018 36 Months From Approved 08/31/2015
400 0 400
800 0 800
0 0 0

When SSA imposes a civil monetary penalty (CMP) on individuals for various fraudulent conduct related to SSA-administrated programs, those individuals may request to pay the CMP through benefit withholding, or an installment agreement. To negotiate a monthly payment amount, fair to both the individual and the agency, SSA needs financial information from the individual. The agency uses Form SSA-640 to obtain the information necessary to determine a monthly installment repayment rate for individuals owing a CMP. The respondents are recipients of Social Security benefits and nonentitled individuals who must repay a CMP to the agency and choose to do so using an installment plan.

US Code: 42 USC 1320 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  80 FR 7521 02/10/2015
80 FR 19102 04/09/2015
No

1
IC Title Form No. Form Name
Financial Disclosure for Civil Monetary Penalty (CMP) Debt SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 400 400 0 0 0 0
Annual Time Burden (Hours) 800 800 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$5,240
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/28/2015


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